Clinical Documentation Matters

Another Biggest CDI Challenge winner, Stacey Forgensi, is announced.  You can read Stacey's complete story on the home page of the CD Matters website.  I just wanted to re-emphasize here in the blog why I chose Stacey's story.  Stacey's is a story of true challenge in employing a multi-tiered strategy to obtain accountability from the physicians for their clinical documentation practices.  Her's is a bittersweet, yet familiar ending, with surgeons choosing to abstain and family medicine physicians all in favor.  Here are some of the many strategies Stacey used to obtain accountability, taken directly from her story:

No matter how you slice it, clinical documentation improvement is about change.  And, my research has shown that physicians involved in a new CDI program are most concerned about whether they will have "enough time to document properly."  Ironically, after the training sessions we conducted with physicians in our studies, 78 percent felt as though they were actually able to document more efficiently because they felt more confident about what they were documenting.  None the less, time management is an issue for physicians. Period.  Therefore one of the resources we've compiled is a Time Management Guide for Physicians.  While the guide is useful for CDI programs, physicians can benefit from the content at anytime.  We pulled research together that looked at what worked best for physicians as well as non-physicians and melded it into a simple 30-page document that you can share with your medical staff.   The other resource Change Management for Clinical Documentation describes the 8 essential activities for successful change management and can be used in either initial implementation of a CDI program or to improve an existing one.  Will be writing more about these two resources and Time and Change management in the weeks to come.  In the meantime, enjoy!

This week marks the beginning of the announcements of the winners of the Biggest CDI Challenge.  Our first winner is Salath Hard from Multicare Health Systems.  Salath's story was chosen because she addressed two important issues quite eloquently.  The first was a career change from an ED nurse to a CDI professional.  Her story, which you can read in full on the home page of the website, details her feelings about the change as well as why she made the change - I think many of Salath's peers will benefit from reading about how she managed the change.  Second, Salath also addressed the issue of why we want to improve documentation.  She is quite persuasitve in her description of the government changes, severity issues, and patient benefits of improved CDI.  I hope you will take the time to read What a Difference a Word Makes by Salath Hard.

Many years ago, I had the task of hiring computer programmers to create some healthcare software.  While I knew alot about the subject matter and the content for the programs, I knew nothing about programming or the people who did this for a living.  And, I realized quickly, that you don't conduct an interview with a programmer in the same way that you do for a marketing assistant or an HR manager.

A few physicians remained behind after the conclusion of a CDI training session at an academic medical center. There were some general comments about how much the hospital might benefit economically from improved clinical documentation.  But then one of the organization's physician leaders, an orthopedic surgeon, offered the following example of how he makes decisions about which patients need a joint replacement.  He said, "It's simple, if my kid's tuition is due, the patient needs a replacement.  If I'm leaving on a tropical vacation, then they can get by with conservative treatment." 

Reading through the contest entries for the Biggest CDI Challenge, it was easy to see a trend, a common theme for most of the submissions.  Most entrants talked about the problems they had getting physicians to attend CDI training sessions or responding to queries.  Many talked about the lengths they went through to get physicians' attention on the topic of clinical documentation.  One of the winning entries used the phrase "permanently modifying physician behavior" as a goal.  At the core of all of these challenges is the same question, "How do we get physicians to care about clinical documentation practices?" 

For those of you who have been following the contest and/or who submitted entries, I would like to thank you for your contributions and support of high quality clinical documentation practices!  I have selected the winners and have notified them today. I am waiting for their replies to my email notification to make the announcment on the blog, so you should hear more about the results in a day or two. 

During one of the pilot studies for the CAMP Method CDI Training studies, a group of 16 physicians at a suburban Philadelphia hospital agreed to be ginea pigs for the program design.  As a first step, I asked them to take the pre-test, which would rate their pre-existing knowledge of clinical documentation.  At one point, I noticed pained looks on the faces of most of the physicians.